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„4, APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT %SC 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin t Local Health District. Job Address Ciiy Lot Size PM Owner's Name33 fi Address Phone (�J� Contractor hl�u-3 —Address 3o�T License No.� Phone_! O F TYPE OF WELL/PUMP: NEW WELL CJ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of.Well Excavation ' Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing t Specifications `l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ r 1 1 Irrigation ---Approx. Depth l 1 Eastern Surface Seal Installed by - F y Repair Work Done ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing )Material (top 50') ' Depth Filler Material (Below 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION l septic system permitted if public sewer is available within 200 feet.) Installation will serve: Res ence Commercial_ Other ` Number of living units: Number of bedrooms bV Character of soil to a depth of 3 feet.— Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments z i PKG. TREATMENT PLT- ❑ r Method of Disposal Distance to nearest: -Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance;to nearest: Well Foundations Property Line F r 1Y SEEPAGE PITS 11 Depth � Size Numbet SUMPS F1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ► `I".ate I hereby certify that I have prepared this application-and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San)Joaquin•-L-ocal,Health Di'stiict..._ Home owner or licensed agent's signature certifies the-fbilowing: "I certify that in the performance of the work for which this permit is issued, I shall not empi person in such manner as to become subject.to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifi the /lowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws C "fom a.” The applicant u II for II r uir inspec o s:-- eta wing on reverses e. Sign Date: r r� FOR DEPARTMENT USE ONLY Application Accepted by "A C131 __ Date =Z� � Area t Pit or Grout Inspection by Date Final Inspection by 2Date Z Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r , FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH sily a,EH t3-24/REV.l/A 51 EH 14-29 �/ � fI 11